Provider Demographics
NPI:1790970200
Name:BOLLAERT'S ILLINI DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:BOLLAERT'S ILLINI DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MELIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:309-796-2251
Mailing Address - Street 1:2909 19TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-5019
Mailing Address - Country:US
Mailing Address - Phone:309-796-2251
Mailing Address - Fax:309-796-2274
Practice Address - Street 1:2909 19TH ST
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-5019
Practice Address - Country:US
Practice Address - Phone:309-796-2251
Practice Address - Fax:309-796-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty